Company: <<Pol_Company>>

Policy #: <<Pol_PolNum>>

Agency: <<Agncy_Name>>

Named Insured: <<Cli_NamedInsureds:PC>>

Effective <<Input:Input the effective date>> please remove <<Input:name of person being removed from policy>> as a named insured and driver from the above listed policy.

Please remove the following item(s) effective the above listed date as I have secured my own coverage: <<Input:vehicles/property removed or N/A>>

I need to be listed as an additional insured on the following items as I still have an insurable interst in them: <<Input:Still has insurable interst in or N/A>>

My new address is: <<Input:enter address of person leaving the policy or enter N/A>>.

Removed named insured and driver signataure:

______________________________________________________

Date:_______________________